Overview of diabetes

What is the definition of diabetes mellitus Diabetes mellitus (DM) is a group of metabolic disturbances, characterized mainly by hyperglycaemia, and finally resulting in the appearance of various complications (macro- and micro-angiopathy, etc.). These complications relate basically to the heart, the vessels, the eyes, the kidneys and the nervous system. Hyperglycaemia is a result of defects in the secretion or action of insulin, or both. According to the latest classification, there are four...

When is admission into hospital recommended

Admission to hospital is recommended in the following cases 1. when poor glycaemic control is accompanied by an alteration in the level of conscience 2. ketonuria or ketonaemia are present and persist for more than six hours, despite the administration of insulin, carbohydrates and fluids 3. blood glucose levels are > 400 mg dl (22.2 mmol L) in more than two repeated measurements, despite the administration of rapid-acting insulin. 4. inability to get hydration by mouth. CASE STUDY 1 A 30...

How do the schemes with premixed insulin preparations work

In these schemes, individualization again constitutes the golden rule. The choice of the most suitable mixture, but also the dosage of insulin, depends on many factors, including the age of the patient, his or her nutritional programme, his or her physical activity, renal and hepatic function, etc. The most 'popular' mixtures are those that contain 30 percent rapid or very rapid-acting insulin and 70 percent intermediate-acting insulin (Figure 28.4). Usually, 2 3 of the total dose are given in...

What are the indications for insulin administration in Type DM

Patients with Type 2 DM manifest a disturbance both in the action of insulin (insulin resistance) and in its secretion, which is decreased. During the natural course of the disease, the disturbance of insulin secretion progressively worsens. Ultimately, most Type 2 diabetics will need exogenous insulin administration. In the UKPDS study, 80 percent of the patients who were initially treated with a sulfonylurea, needed insulin after nine years. The main indication for insulin administration in...

What should be done with regard to the glycaemic control of this patient

The patient obviously manifests secondary failure of the oral antidiabetic drug treatment. The diagnosis of DM was done 15 years before, she receives almost the maximal dose of glibenclamide and her body weight is only slightly increased. The above data suggest a serious disturbance of insulin secretion. The addition of a second medicine (for example, metformin) is not expected to decrease HbA1c more than 1.5 percent. The beginning of insulin treatment was recommended to the patient, but she...

How do you diagnose peripheral diabetic neuropathy

The diagnosis is based on physical examination. First of all, inspection can reveal atrophy of intraosseous muscles in the hands and feet, a sign of denervation. When muscle atrophy in the feet is extensive, deformity of the foot architecture can occur, characterized by high foot arch, metatarsal head protrusion, and a shift of the subcutaneous fat normally present under the metatarsal heads towards the bases of the toes, resulting in claw-toe deformity. When autonomic neuropathy coexists,...

List Of Authors

1st Department of Propaedeutic Medicine of the Athens University Medical School The Diabetes Center, 'Laiko' General Hospital Athens, Greece 1st Department of Propaedeutic Medicine of the Athens University Medical School The Diabetes Center, 'Laiko' General Hospital Athens, Greece 1st Department of Propaedeutic Medicine of the Athens University Medical School The Diabetes Center, 'Laiko' General Hospital Athens, Greece 2nd Department of Internal Medicine Diabetes Clinic, Agia Olga General...

How frequent are the ulcerations of the feet and what is their significance

The prevalence of feet ulcerations in diabetic persons is in the order of 4-10 percent, whereas their incidence is 2.2-5.9 percent per year. Ulcer frequency is lower in younger persons aged less than 45 years (1.7- Figure 17.2. Neuroischaemic painful ulcer on the lateral surface of the heel. A second smaller ulcer is observed on the head of the 1st metatarsal. The base of the ulcer is necrotic. The presence of skin cracks is evident due to neuropathy and anhidrosis. Figure 17.2. Neuroischaemic...

Which cutaneous manifestations occur in other endocrine and metabolic disorders that are related to DM

Acanthosis nigricans is characterized by hyperpigmentation of the skin in regions where this forms folds, as in the axillae, the neck and the groins (Figure 18.4). Generalized acanthosis nigricans is usually related to development of neoplasia, mainly of the gastrointestinal tract, whereas the more limited form is related to conditions of insulin resistance, such as obesity, Type 2 DM, the polycystic ovary syndrome and acromegaly. Eruptive xanthomata are due to deposits of triglycerides in the...

How would you advise the patient now based on these findings

As already mentioned, diabetic retinopathy is divided into non-proliferative DR (NPDR or background DR) and proliferative DR (PDR) depending on the presence or not of neovascularization of the retina (in the area of the optic disk or the periphery), and it can, at any stage, be accompanied by diabetic maculopathy. Studies in Type 1 diabetic patients (DCCT, 1995) showed that good glycaemic control based on intensive insulin therapy decreased the risk of DR by 76 percent, after the first 36...

Artificial Pancreas

This concerns appliances that measure the concentration of glucose and through special algorithms administer the proper dose of insulin to the patient, usually intravenously or and subcutaneously. These appliances are currently used mainly for research reasons, and their perfection is anticipated. A serious technical problem derives from the fact that the electrode that measures the glucose concentration gets inactivated after some days. Significant contributions to this field have come from...

What is the main benefit of the use of inhaled insulin

Obviously, the main benefit is the avoidance of injections for the administration of rapid-acting insulin. From clinical studies up to now which are small and of short duration so far , satisfaction from its use is definitely higher for patients, compared to the use of subcutaneous insulin. It can be expected that in particular patients with Type 2 DM who refuse treatment with subcutaneous insulin after secondary failure of oral antidiabetic medicines will be controlled better if they are...

How often should BP be measured in diabetic patients What is the recommended method of followup

BP should be measured at diagnosis of DM and then at each doctor's visit. Due to the variability of its measurement, proper conditions and the right technique are of utmost importance for correct recording. The dimensions of the sphygmomanometer cuff should properly fit the size of the patient's arm - the length of the cuff should cover at least 80 percent of the circumference of the arm bigger than needed cuffs will show false lower blood pressure values, whereas smaller cuffs will show false...

What is the particular therapeutic characteristic of meglitinides

Meglitinides have a rapid onset and rapid end to their hypoglycaemic action. This characteristic renders them useful for the control of postprandial glucose levels and for the avoidance of hypoglycaemias several hours after a meal. Repaglinide and nateglinide tablets are recommended to be taken immediately before a meal. If a meal is skipped, the medicine should not be received. These characteristics are considered as advantages of meglitinides over sulfonylureas. The main undesirable effect of...

Fluid administration and restoration of electrolyte disturbances

Mean fluid deficit amounts to 9-10 L. The administered fluid is isotonic solution of NaCl 0.9 percent and only when Na concentration is gt 155 mmol L is hypotonic solution of NaCl 0.45 percent preferred if this is not readily available, it can be prepared by adding four ampoules of NaCl in one L of water for injection . Generally, it is essential to monitor urine output, vital signs and cerebral function. In elderly people it is also useful to monitor central venous pressure to avoid fluid...

What are the undesirable effects of sulfonylureas

The most important undesirable effect is hypoglycaemia, which is usually manifested after the omission of a meal or generally from the inability to eat food for various reasons. Old age and various coexisting diseases like Addison's disease are aggravating factors for the manifestation of hypoglycaemia and should be taken into account. Situations that prolong the excretion of the medicine's metabolites renal or hepatic insufficiency or other medicines that augment their actions can cause...

What is the cause of the impaired secretory ability of the pcell in Type DM

The exact aetiology of impaired b-cell secretory ability is not completely elucidated, despite the large number of studies in animals and humans. Specific causes of impaired function can be a decrease in b-cell mass, an increased apoptosis decreased regeneration of the b-cells, exhaustion of the b-cells secondary to compensatory hyperinsulinaemia a consequence of long-term peripheral insulin resistance , glucotoxicity and or lipotoxicity in the pancreas and amyloid deposition in large...

Repercussions of DM in sexual life

Erectile dysfunction is defined as the inability of a man to achieve and or maintain sufficient erection for sexual activity. This complication less often called 'impotence' these days often occurs in middle-aged men. In a large study performed in Massachusetts, 52 percent of healthy middle-aged men manifested some degree of erectile dysfunction. The same study showed that the frequency increases with age, while it is three times more frequent in diabetics compared to non-diabetics of a similar...

What is acarbose chemically and how does it act

Acarbose is a pseudo-tetrasaccharide, a biotechnology product. It contains acarbiosine, which resembles a disaccharide, connected with a maltose residue via an a-glucosidic bond. Acarbiosine is recognized and gets bound to the glucosidases of the intestinal brush border. This results in the inhibition of carbohydrate hydrolysis and the delay of their digestion in the duodenum and jejunum during the first two hours after the meal. This effect is dose-dependent. Acarbose is excreted unaltered by...

What are the thiazolidinediones and how do they act

A new category of antidiabetic medicines consists of thiazolidine-diones TZDs or glitazones. the main action of which is the reduction of insulin resistance in the peripheral tissues mainly the adipose tissue, but also the muscles and less so the liver . The first medicine of this category troglitazone came out in the USA in 1997, but was withdrawn in 2000 because of serious hepatotoxicity. Today two substances of this category are available, pioglitazone and rosiglita-zone. TZDs bind to...

What are sulfonylureas and which type of DM are they indicated for

These are substances with a chemical structure similar to the sulfonamides that have a hypoglycaemic effect. Initially 1956 tolbutamide was discovered, and then chlorpropamide 1957 , acetohexamide 1963 and tolazamide 1966 . These were called first generation sulfonylureas. Today these substances are barely used, since the second generation sulfonylureas are now available Table 27.1 , that is, glibenclamide 1969 , gliclazide 1972 , glipizide 1973 and glimepiride 1994 . This latter substance is...

Further reading

Beckman, J., Greagen, M., Libby, P. 2002 Diabetes and Atherosclerosis. JAMA, 287, 2570-81. Bjorntrop, P. 1992 Regional obesity, in Obesity. eds P. Bjorntrop and B.N. Brodoff . J.B. Lippincott Co, New York, pp. 576-86. Colhoun, H.M., Betteridge, D.J., Durrington, P.N., Hitman, G.A., Neil H.A., Livingstone, S.J., Thomason, M.J., Mackness, M.I., Charlton-Menys, V., Fuller, J.H. 2004 Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin...

In what dosage are meglitinides available

Repaglinide is available in 0.5, 1 and 2 mg tablets. It is administered at a dose of 0.5-4 mg before each meal and has an elimination half-life of one hour. It is excreted in the stools. It can be used as monotherapy in individuals with Type 2 DM who cannot control their disease with diet alone, or it can be used in combination with metformin. Nateglinide is available in 60, 120 and 180 mg tablets. It is usually administered at a dose of 60-120 mg before each meal and has an elimination...

What are the indications and contraindications for acarbose

Acarbose is indicated first of all in the prevention of post-prandial hyperglycaemia in individuals with Type 2 DM. Its effectiveness is limited to a decrease of glycosylated haemoglobin by 0.5-1.0 percent when used as monotherapy. It can be combined with a sulfonylurea, metformin, insulin and with the combination of two or even three substances see the first footnote in Figure 27.1 . In all cases, however, its effectiveness is most apparent when the severity of the disease is relatively small....

What is the fate of undigested carbohydrates and what undesirable effects can be produced by their presence in the

Undigested carbohydrates are removed with the stool. However, in the large intestine, the normal intestinal flora causes fermentation of the redundant carbohydrates and local excessive production of the products of this fermentation lactic acid, hydrogen, carbon dioxide, etc. . As a consequence, those substances that are not absorbed cause flatulence, abdominal aches, diarrhoea or excessive production of gases. To some degree these complaints can be avoided with progressive increase of the dose...

What is the mechanism of action of meglitinides

They are bound to the sulfonylurea receptor of the pancreatic b-cell membrane and cause secretion of insulin. The binding occurs at a different part of the receptor compared to sulfonylureas, but as with sulfonylureas, closing of the potassium channels follows, with a subsequent depolarization of the membrane, opening up of calcium channels and entry of calcium ions into the cell. The increased intracellular calcium ions concentration ultimately causes the mobilization of the secretory insulin...

Apart from their action on the pancreas are there extrapancreatic actions of sulfonylureas

Sulfonylureas directly or indirectly influence other metabolic indices as well. For example, glibenclamide was shown to improve post-prandial hypertriglyceridaemia, by decreasing chylomicron concentrations. It also restricts the post-prandial activation of coagulation, by decreasing fibrinogen, the thrombin-antithrombin complexes and the D-dimers. For gliclazide, a favourable action on the retina of diabetic patients has been reported. Very interesting experimental data have also been reported...

How is increased capillary permeability explained in DM

There is a decrease in pericytes in DM, i.e., the supportive cells of the capillary walls, which have myofibrils and regulate the volume of blood that passes through the capillaries. As a result, the capillary wall is locally dilated and microaneurysms form, with resultant fluid or cellular components leak. Furthermore, hyperglycaemia causes loosening of the junctions between endothelial cells, resulting in breakage of the retinal barrier and diffusion of cellular and non-cellular components of...

Pathophysiology of Type diabetes

What are the main pathophysiologic characteristics of Type 2 diabetes mellitus Type 2 diabetes mellitus is a heterogeneous syndrome, with a complex interaction of genetic and environmental factors, which affect multiple phenotypic manifestations in the body, such as insulin secretion and action, pancreatic b-cell mass, distribution of body fat and development of obesity. Type 2 DM is generally characterized by two main pathophysiologic entities i resistance to the action of insulin and ii...

How is a sulfonylurea selected and how is it administered therapeutically

The choice is based on the potency, the dosage see Table 27.1 , the method of metabolism and the probability of causing undesirable side effects. Benefits from their usage, apart from control of blood sugar, that differentiate the second generation sulfonylureas from each other, are discussed below. Sulfonylureas should be administered 20 minutes before meals, since they achieve drastic levels in the blood circulation one hour after their absorption by the peptic system. In any case, during...

Case Study

A 19 year old woman, of normal weight, with positive family history of DM in her father and grandfather with onset of the disease at a young age in both manifests, at a medical check up, mild hyperglycaemia blood sugar 155 mg dl 8.6 mmol L . This is confirmed in repeated measurements. No ketoacidosis is ever present. What type of DM does this patient have The positive family history of DM, with a young age at onset in two generations, implies the presence of some hereditary type of DM. The age...

How much do the antidiabetic medicines decrease glycosylated haemoglobin

The degree of glycosylated haemoglobin reduction is, apart from any other factor, also dependent on the correct indication for the administration of each medicine separately. As was mentioned before, Addition of sulfonylurea or meglitinide or thiazolidinedione Long acting insulin at bedtime combined with pills except TZDs Mixture of insulin rapid acting with slow-acting twice a day. Discontinuation of pills or continuation of metformin Multiple injections regimen if flexibility is required At...

Transplantation Of Kidney And Pancreas Case Study

A 28 year old woman with Type 1 DM since the age of nine visits the outpatient Diabetes Clinic for follow-up. Her weight is 62 kg 136.7 lb and height 1.55 m 5 ft 1 in . On physical examination she looks pale and oedematous. The thyroid gland is palpable. The heart sounds are normal, and an apical holosystolic murmur is heard II VI . The subcostal organs are not palpable. The Achilles and patellar reflexes were not produced and there was ankle oedema. There is no superficial or deep sensory...

What are the main skin manifestations in DM

Bullosis Diabeticorum Picture

Certain cutaneous disorders appear to be specific for DM for example, diabetic thick skin , whereas others are present in the general population but are more frequent in diabetic individuals. Diabetic dermopathy is the most common skin disorder associated with DM. It is quite frequent and presents at a rate, according to various authors, ranging up to 50 percent in diabetic patients, but only 3 percent in the general population. It is more prevalent in men older than 50 years of age, with...

What does the speed of insulin absorption after a subcutaneous injection depend on

After the injection, a reservoir of insulin is created at the point of infusion, which is then progressively absorbed from the capillaries of the region and enters the circulation. The speed of absorption of the subcutaneous reservoir depends on a number of factors The insulin compound. Every type of insulin has a different profile of absorption. The rapid acting soluble insulin reguar insulin is injected subcutaneously in the form of insulin hexamers. These are diffused in the subcutaneous...

How do you establish the diagnosis

Diagnosis is based on the patient's history and discovery of blood pressure fall with position change, as mentioned above. The evaluation is performed as follows the patient is supine for about 15 minutes when the blood pressure is measured. Subsequently, the patient is asked to stand up and stay standing for five minutes. Blood pressure is measured every minute for a total of five minutes and the difference of the lower blood pressure value in the standing position compared to that in the...

What is diabetic maculopathy

Diabetic Maculopathy Pictures

Diabetic maculopathy is characterized by the presence of microaneurysms, flame-like haemorrhages, cotton-wool like or even hard exudates Figure 13.1. Photograph of the retina of the patient showing multiple exudates, micro-haemorrhages and micro-aneurysms on the macula area, as well as scars from previous Laser photocoagulation. Figure 13.1. Photograph of the retina of the patient showing multiple exudates, micro-haemorrhages and micro-aneurysms on the macula area, as well as scars from...

How is the transplantation of the kidney and pancreas done

Usually the kidney is transplanted extraperitoneally in the left lower quadrant and the pancreas intraperitoneally with part of the duodenum in the right lower quadrant. The pancreas is removed from the donor together with the liver, so that damage of the blood vessels that perfuse them is avoided, and then their separation follows. The pancreas can be maintained in a University of Wisconsin solution special buffer solution for up to 30 hours. The arterial perfusion of the pancreas is ensured...

How is the transplanted patient monitored for episodes of rejection

Langerhans Islet Parasympathetic

Usually, rejection concerns the cells of the exocrine part first, with the islets are rejected later. Therefore, monitoring of glycaemic control is not a reliable tool for the follow-up of the patient. The rejection of the pancreas only is less frequent than the rejection of both organs. In cases where the pancreas has been drained in the urinary bladder, the urinary amylase levels are monitored, which decrease when a rejection occurs but in the case of intestinal drainage, this is not...

How are ulcers classified

Apart from their classification to plain neurotrophic, plain ischaemic and neuroischaemic ulcers, as mentioned earlier, there are two classification systems for the severity of the ulcers. Traditionally, classification by Meggitt-Wagner was considered as the 'classification of choice'. Relatively recently, however, a new classification system was proposed by the University of Texas in the USA, which is considered to be superior. Its main advantage is that it takes into consideration the...

How is the substitution of basal insulin secretion done

Regular Insulin Peak And Duration

The substitution of basal insulin secretion is achieved by administering one or two insulin injections of intermediate or slow duration of action daily. More precisely Isophane insulin NPH . An injection before bedtime is first administered. The reason for this particular time lies in the avoidance of nighttime hypoglycaemia if the injection is given earlier, the peak of action will coincide with the first morning hours of high insulin sensitivity, when the risk of hypoglycaemia is increased ....

Case Study About Osteomyelitis

A 26 year old woman has suffered from Type 1 DM since the age of five years. Her insulin regimen includes pre-prandial administration of insulin lispro and once a day administration of insulin glargine. Lately, her glucose control has deteriorated significantly and there is great variability in her measurements. She is affected by the occurrence of 'unpredictable' hypoglycaemias, for example, one hour after a meal. When asked by her physician, she reports that her stomach feels full even many...

Protocol

This was used in the Swedish DIGAMI-1 study . Prepare a solution with 80 units rapid-acting insulin in 500 ml 5 percent dextrose in water D5W . Start an infusion at 30 ml h. Measure blood glucose every 1-2 hours. We adjust the solution infusion according to Table 16.3. The intravenous infusion of insulin is continued for 2-3 days. When the patient starts feeding, subcutaneous administration of insulin is initiated. Based on the DIGAMI-1 results, some authors propose insulin Table 16.3. Insulin...

What are the pharmacotechnical forms of inhaled insulin

Insulin can be inhaled in different forms, depending on how it has been Dry powder. This is inhaled with the Exubera system of inhalations, from Pfizer Inc. and Aventis Pharma, in collaboration with Nektar Therapeutics. This system is already evolving technologically and was very recently been approved in January 2006 by the FDA for clinical use. It is soon expected to be available in Europe. Aerosol nebulized via the AERx inhalation system produced by Aradigm in phase III studies . 'Artificial...

When should microalbuminuria be checked

As mentioned earlier, microalbuminuria is present in 10-42 percent of Type 2 diabetic patients at diagnosis, since the disease has most likely been silently present for many years before its clinical manifestation. For this reason, measurement of albumin excretion rate is recommended at the initial diagnosis of diabetes, and then yearly, if it is within normal limits initially. As regards Type 1 DM, a check of the albumin excretion rate is recommended five years after the initial diagnosis -...

Why was metformin recommended for this particular patient

The patient did not manage to decrease his blood sugar to desirable levels with diet and exercise. This is the indication for metformin - the only biguanide available - as monotherapy. This particularly concerns obese individuals, since the administration of the medicine is not associated with weight gain as happens with other medicines and potentially causes a small weight loss. Metformin is also useful in patients that need to maintain the weight loss achieved with diet and exercise. It is an...

What are the effects of exercise in a diabetic person

Physical activity has both acute and chronic effects in the diabetic person, which differ depending on the type of DM Type 1 or 2 . During exercise in normal persons, pancreatic insulin secretion decreases as already mentioned in response to the increased insulin sensitivity brought about by exercise. In persons with Type 1 DM, however, that use insulin injections for their treatment, this physiological decrease in insulin secretion cannot happen, because insulin has been exogenously...

Biguanides Metformin Case Study

A 40 year old man with a family history of DM comes to the Diabetes Clinic for the second time, three months after his first visit. At the first visit he had been diagnosed as having Type 2 DM, which had manifested after intense family problems, with typical symptoms polyuria and polydipsia and balanoposthi-tis. At that time the patient weighed 102 kg 224.9 lb and had a body mass index of 33.6 kg m2. He had an office job, sitting for long hours, and smoked roughly 30 cigarettes a day. He drank...

When can DM cause reversible haziness of the lens

Multiple reversible haziness of the lens can occur rarely in patients with Type 1 DM children or young adults after severe hyperglycaemia and evolve over days or weeks 'snowflake cataracts' . This condition is gradually reversed with control of diabetes. Similar but less intense episodes can be seen in diabetic patients during periods of poor control of their diabetes. This happens more frequently, is manifested with transient refractive visual abnormalities - mostly myopia - which are...

Necrotizing fasciitis and myonecrosis

This is a very serious infection of the soft tissues, accompanied by clinical signs of sepsis and constitutes an emergency condition. The infection begins from the subcutaneous tissues and spreads deeper. It is distinguished as either monomicrobial streptococci are the responsible microorganisms or polymicrobial caused by enterobacteria and anaerobic bacteria - mainly clostridia . The most common sites of infection include the upper and lower extremities and abdominal wall. Mortality reaches 40...

Urinary tract infections

Most studies agree that women with DM have a 2-4 times higher incidence of bacteriuria compared to those without diabetes. Asymptomatic bacteriuria is also definitely more frequent in diabetic women. Nevertheless, the clinical and microbiological characteristics of urinary tract infections do not appear to differ compared to the general population. DM constitutes a predisposing risk factor for the development of serious infections of the upper urinary tract. Thus, diabetic individuals manifest...

Cheiroarthropathy

Many patients with Type 1 DM up to 30 percent , especially those with long duration of the disease, manifest waxy skin and stiffness of the small and large joints. This damage is correlated with the presence of microvascular complications. The involvement of the small hand joints leads to the characteristic inability of palmar surfaces approximation Figure 20.1, the prayer sign and the inability of complete extension of the palm. The skin on the dorsal surfaces of the hands is hard, waxy and...

What common situations during a journey can cause problems in the control of DM

Dietary habits should be maintained, as much as possible, during a journey. The food offered in the plane is sometimes inappropriate for diabetics, either because it is very low or very rich in carbohydrates. When travelling abroad, there is often no familiarization with the various local foods content in carbohydrates so a problem with glycaemic control can occur. Thus, in the beginning at least, it is wise to stick to international cuisine, if available, and to try unfamiliar foods in small...

How do sulfonylureas act

Sulfonylurea Mechanism

Sulfonylureas are bound to a part of the b-cell cytoplasmic membrane potassium channel, called the sulfonylurea receptor SUR, see Figure 27.1 . This binding causes inhibition of the exit of potassium ions from the b-cell and a change of the cell's resting potential. This results in the opening of special calcium channels of the cytoplasmic Figure 27.1. Mechanism with which glucose and sulfonylureas cause insulin secretion from the -cell. Reprinted from Textbook of Diabetes, 3rd edn., J. Pickup...

Skin infections

The view that cutaneous infections are more frequent in diabetic individuals has recently been disputed. Perhaps the better control of DM with oral medicines and insulin has contributed to a reduction of severe dermal infections. Furuncles, carbuncles, styes and erythrasma were in the past before the introduction of insulin and antibiotics much more common in diabetic individuals, but now their frequency has definitely decreased. Furuncles and carbuncles are due to Staphylococcus, and...

How can you rule out or confirm the diagnosis of osteomyelitis

Osteomyelitis Pathophysiology

All chronic ulcers, particularly when their dimensions are more than 2 cm, can be complicated by osteomyelitis. Acute osteomyelitis manifests radiological findings two weeks after involvement of the bone. These consist of osteolysis or even a significant degree of bone absorption, with or without periosteal reaction Figure 17.8 . It is recommended Figure 17.8. The X-ray of the patient with the ulcer Figure 17.7 . Osteolysis of the head of the 1st metatarsal and the proximal part of the last...

Osmotic pressure or Osmolality mOsmkg [Na mEqL K mEqL Glucose mgdl Urea mgdl

If increase in plasma osmolality is greater than 340mOsm kg H2O, lethargy or coma is justified. Despite this, many people with lower osmolality values have clouding of sensorium, to which other factors seem to contribute as well hyperketonaemia alters brain oxygen consumption and the frequently underlying disease sepsis, etc. are the most common. 1. Immediate priority Rehydration - restoration of intravascular volume, aiming at restoring blood pressure, pulse rate and diuresis 2. Control of...

On the followup visit SMBG values pre and postprandial remained unchanged HbAc was percent HPLC method and the rest of

There is an obvious inconsistency between HbA1c and the SMBG values of the patient. According to SMBG values, HbA1c should be much higher see Table 4.2 . When there is a discrepancy between these two parameters, which anyway are just the basic methods of glycaemic control evaluation, the physician has to discover the cause and clarify which of the two values correctly reflects the patient's glycaemic status. There are, consequently, two alternatives B deceptive indications of SMBG. Possible...

Which factors can affect the HbAc value

Any condition that reduces the duration of life of the red blood cells or their mean life-span haemolytic anaemias or an acute haemorrhage , leads to falsely low HbA1c levels, regardless of the method used for its determination. Hypertriglyceridaemia, uraemia, elevated bilirubin and alcoholism have been reported to influence chromatography methods, resulting in falsely elevated HbA1c values. Haemoglobinopathies affect some of the methods regardless of their effect on red blood cells' life span....

Contents

Pathophysiology of Type 1 diabetes Ioannis Ioannidis 23 Pathophysiology of Type 2 diabetes Konstantinos Makrilakis 43 Acute illness in diabetes Stavros 103 Diabetes and exercise Konstantinos Makrilakis 109 Diabetes and pregnancy Panagiotis Tsapogas 121 Diabetes and the young Ioannis 141 Diabetes and old age Konstantinos 147 Diabetic nephropathy Evanthia Diakoumopoulou 173 Macroangiopathy in diabetes Ioannis Ioannidis 199 Skin disorders in diabetes Konstantinos Makrilakis 243 Sexual function and...

What are the main undesirable side effects of TZDs and with what mechanisms have they been explained

Ankle oedema constitutes an undesirable side effect of TZDs manifesting at a rate of 4-5 percent of patients. Fluid retention, which is partly responsible for the increase of body weight that is observed in patients treated with TZDs, can decompensate preexisting cardiac insufficiency, or cause the development of cardiac insufficiency that was not previously diagnosed. In this case, diuretics do not help and discontinuation of the TZD is imperative. If insulin is coadministered, the oedema can...

What are the lipoproteins and what are they used for in the body

Endogenous Lipoprotein Metabolism

Because lipids are insoluble in water, they cannot circulate freely in the blood. For this reason, they are linked with special proteins the apolipo-proteins or apoproteins and form complex substances the lipoproteins that are soluble in water and can be transported through the blood circulation all over the body. More specifically, the lipoproteins contain a lipid core from free cholesterol, cholesterol esters, triglycerides and phospholipids and a protein cover, the apolipoproteins....

How frequent is Charcot arthropathy and which persons are at risk of developing this complication

Charcot neuroarthropathy is an infrequent but important condition, which is recognized more often if the physician is sensitive to the complication. It equally affects men and women, both with Type 1 and Type 2 DM. The mean age of appearance is 60 years and the known duration of DM is at least 10-15 years. In order for Charcot arthropathy to manifest itself, severe peripheral neuropathy, neuropathy of the autonomous sympathetic nervous system and sufficient blood perfusion of the foot should be...

Dupuytren syndrome and carpal tunnel syndrome

Diabetic Cheiroarthropathy

People with DM manifest carpal tunnel syndrome as well as Dupuytren syndrome more often contracture of the palmar fascia, Figure 20.2 . This contracture is indeed present in up to 63 percent of diabetics. The third and fourth fingers are involved more frequently the small finger is not involved as in classic types of the disease . Furthermore, there are often sclerotic nodules on the heels and on the dorsal surfaces of the central interphalangeal joints Garrod's nodules . Figure 20.1....

What are the contraindications for the administration of metformin

Metformin is strongly contraindicated in situations that can constitute a background for the appearance of lactic acidosis see below for more details . The medicine is also contraindicated in patients with impaired renal function serum creatinine gt 1.5 mg dl 132.6 mmol L in men or gt 1.4 mg dl 123.8 mmol L in women . In elderly patients, the decision whether to administer metformin is based on the creatinine clearance metformin should not be prescribed if this is lt 60 ml min 1.73 m2 . The...

What is the classification of gestational diabetes

Gestational diabetes is classified as a separate form of DM. It is not uncommon, following the occurrence of gestational diabetes, for the condition to continue after delivery, either in the form of Type 2 DM or even as a first occurrence of Type 1 DM. It should be noted that during the course of a normal pregnancy there is resistance to the action of insulin which causes increased circulation of glucose and free fatty acids, so that adequate supply of these nutrients is available for the...

What particular precautions should be taken during long air journeys when a time difference exists

The problem with time difference concerns primarily individuals who use insulin treatment and is connected mainly with the injections of long acting insulin. In these travels, when the plane flies from east to west, the 24-hour day 'is elongated'. Thus, the first long-acting insulin injection in the destination, if based on the local time, will be later after the previous one that was injected in the place of departure than usual. If the difference of time is small lt 4 hours , no significant...

What is the current state of pramlintide in the market

The substance medicine Symlin, pramlintide acetate, produced by Amylin Works has passed the phase III clinical studies and has been administered to a total of 4,800 individuals so far. In the year 2000, an application was submitted to the FDA to allow its promotion in the market but the FDA asked for more explanatory data in the following years. In March 2005 its circulation was approved in the USA as an adjunct treatment for Type 1 and 2 diabetics on insulin who have failed to achieve...

When does a woman with gestational diabetes need to start insulin treatment and what regimens are followed

As mentioned above, when diet is not enough to achieve therapeutic targets, insulin therapy is required, usually after a period of a few days of self blood glucose monitoring with levels above these desired. It is usually postprandial blood glucose levels that are higher than accepted cut-offs. The mother should be told that injected insulin does not cross the placenta and does not affect the foetus. In contrast, increased blood glucose crosses the placenta and is responsible for possible...

What is the effect of TZDs on serum lipids

Most studies agree that TZDs increase HDL-cholesterol by 10-14 percent, decrease free fatty acids and contribute to the increase in size of small-dense LDL molecules, which has a beneficial effect on the risk for atherosclerosis. Moreover, they do exert a mild hypotriglyceridaemic effect when the triglycerides are gt 200 mg dl 2.3 mmol L . It should also be mentioned that modern pharmaceutical research is directed towards the development of products that are simultaneously PPAR-g and-a...

Case Study Lactic Acidosis

A 74 year old woman presents to the hospital with complaints of recent high blood glucose levels and a feeling of progressively deteriorating fatigue. Her family members report episodes of lethargy and intense sleepiness, as well as confusion during the previous week. The patient suffers from DM for 12 years , hypertension, coronary heart disease, dyslipidaemia, heart failure and atrial fibrillation. An echocardiogram done three months before showed left ventricular hypertrophy, mitral...

How is macrosomia defined and how is it caused

Macrosomia is defined as the condition during which the neonate's body weight at birth is higher than the 90th percentile for gestational age or higher than 4 kg 8.82 lb . Macrosomia occurs in every type of diabetic pregnancy unless there is angiopathy. Neonates are large and corpulent, with an excessive accumulation of fat in the abdomen and shoulders. Furthermore, visceral enlargement occurs. Macrosomia predisposes to trauma during delivery, especially shoulder dystocia, which is prevented by...

Charcot neuroarthropathy

Charcot neuroarthropathy is a rare disease 1-2 cases in every 1000 patients in persons with DM. It usually affects monoarthritis the foot tarsal and metatarsophalangeal joints . The characteristics of the person with DM who develops the disease are 1. long duration of the illness gt 10 years 3. usually insulin-dependent DM 4. peripheral neuropathy and absence of pain causative factor 5. coexistence of other complications. This condition is due to invisible small trauma and microfractures that...

Case Study Hyperosmolar Nonketotic Hyperglycaemic Coma Hnkhc

A 75 year old woman with a history of residual left hemiparesis due to a stroke, is transferred to the Emergency Room of the hospital. Recently, the patient has had intense polyuria and complained of profound thirst, the result of consuming of large quantities of juices. During the previous week she had experienced a decrease in her level of consciousness, with gradual clouding of sensorium, slowly deteriorating until she fell into a coma. Physical examination revealed signs of dehydration,...

What is the relationship between cataract and DM

Cataract is 30 percent more common in diabetic than in non-diabetic persons. Cataract development is a physiologic manifestation of ageing, but this process occurs earlier and more quickly in diabetic people. The mechanisms of cataract development in ageing and in diabetes are similar. The polyol pathway has been incriminated in cataract production in experimental models of diabetic animals, with resultant accumulation of sorbitol and galctitol a product of galactose in the lens. This view is...

Malignant otitis externa

This a rare on absolute frequency but potentially lethal infection of the outer acoustic canal. The responsible micro-organism, in the majority of cases, is Pseudomonas aeruginosa. It presents with pain, otorrhoea and reduction of the acoustic acuity, without fever. If the diagnosis is delayed, the infection can spread, resulting in osteomyelitis of the skull and or intracranial infection. Ciprofloxacin is usually prescribed, although in neglected cases surgical treatment may also be needed.

Questions and Answers from Case Studies

Tentolouris P. Tsapogas O SaK apcodz amp Aiaftrtr amp aTZv KliviKr npo ,r O Aiaftr tz amp ano to A to Q me EptotrZaei amp Kai AnavtZaei amp Translated into English by Konstantinos Makrilakis English language translation copyright 2006 John Wiley amp Sons Ltd The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England Telephone 44 1243 779777 Email for orders and customer service enquiries cs-books wiley.co.uk Visit our Home page on www.wileyeurope.com or...